For nearly 20 years, HIV and AIDS have presented historic challenges to our nation's public health, scientific, and medical communities. It is estimated that in the United States, more than 800,000 persons are living with HIV. The number of people living with AIDS is increasing as effective new drug therapies keep HIV-infected persons healthy longer and dramatically reduce the death rate. Despite extremely beneficial advances in HIV/AIDS treatment in recent years, the epidemic is far from over. An estimated 40,000 Americans become infected with HIV every year, and more than half of these are young people under the age of 25. The HIV epidemic is increasingly affecting communities of color -- particularly young people and women. The majority of new infections among men, nearly 60%, continue to be among men who have sex with men (MSM). Recent evidence suggests there has been a resurgence in unsafe behaviors among some communities of MSM. The 2001 National HIV Prevention Conference is unique in that its sole concentration is on the ever-important science of HIV prevention.

HIV Prevention Conference Hits Atlanta

During the week of August 12, Atlanta was the scene for the only HIV/AIDS conference dedicated exclusively to prevention efforts. More than 2,000 AIDS educators, researchers and doctors were at the meeting.

"This meeting is so important because it really provides an opportunity for all the individuals involved in the prevention field to come together and learn from one another," said Dr. Ronald Valdiserri, deputy director of the National Center for HIV, STD and TB Prevention at the CDC. The CDC is one of 20 sponsors of the conference, which is held every other year. While the majority of attendees were from the United States, participation by international representatives allowed AIDS educators to learn about prevention methods being used in other countries.

"The importance for us is that we learn what the best practices are," said Bob Ford, volunteer services manager at AID Atlanta, one of the city's largest AIDS groups. "We can get better ideas to change our programs and enhance the programs that we presently have. We are able to build community with people here in Atlanta as well as across the country."

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Anthony McWilliams, the agency's prevention programs manager, said the conference "really gives an opportunity to bring together gay and bisexual men with heterosexuals to talk about homophobia . . . and the different sexualities to address how these issues actually relate to the transmission of HIV, especially in the African-American community."

Ford said the prevention message has changed since AIDS was first diagnosed 20 years ago. "In the early '80s, the initial campaigns were very sex-negative. Today, campaigns are much more sex-positive, offering people as many choices as possible, trying to get people to make changes that are healthy and viable and reduce the risk of HIV transmission." (Southern Voice (Atlanta), 08/09/01, Eric Erickson)

Era of Decline of US AIDS Cases May Be Over

The dramatic decline in the number of Americans developing AIDS and dying from the disease may be coming to an end, federal health officials from the CDC announced today.

After dropping sharply in the mid-1990s, the number of US AIDS cases and deaths reported quarterly remained stable between mid-1998 and mid-2000, according to new government figures released at the 2001 National HIV Prevention Conference.

Health officials expressed concern about the leveling-off, as well as about new findings that indicate high rates of risky behavior and HIV infection in some population groups, notably young gay men and low-income African-American women.

"The latest data suggest that the era of dramatic declines is over," said Helene Gayle, director of the National Center for HIV, STD and TB Prevention at the CDC. "There are a number of signs indicating that our progress in fighting the disease is in serious jeopardy," she said. "If treatment failures become more of a problem, if resistance becomes more of a problem, we could see increases in deaths as well as in AIDS cases."

Some encouraging trends were also evident from the data reported. Thanks to vigorous efforts to expand HIV testing and treatment to pregnant women, only 156 cases of transmission from infected mothers to newborn infants were reported nationally in 1999, a record low since the start of the epidemic and an 84 percent decrease since 1992. In addition, HIV rates have declined in injecting drug users in areas where testing has been done, Gayle said. In New York City, the proportion of drug users who were infected fell from 50 percent in 1990 to 20 percent in 2000.

The stability in overall numbers of Americans who become newly infected with HIV each year (about 40,000 annually) does not necessarily explain the leveling-off of AIDS cases and deaths from the progress made in the 1990s. Health officials believe the plateau reflects the fact that most people who know they are infected and who have access to health care are now getting treatment that includes highly active drugs against the virus. Health care workers need to expand HIV testing, improve access to treatment and focus on the care of patients who can't tolerate the drugs, fail to follow their medication schedule, or stop responding to the medicines, Gayle said.

The populations that are encompassed in the 40,000 new infections are different, Gayle said. HIV "is reaching younger people, it's reaching more women, it's reaching more communities of color." Forty-two percent of new infections are occurring in gay men, 33 percent in heterosexuals infected during sex, and 25 percent in injecting drug users, she said. Infections in heterosexual women are increasing more rapidly than any other group. A recent CDC study of young gay men in six cities found that 4.4 percent are becoming infected annually with the rate especially high (14.7 percent annually) among African Americans, compared to 3.5 percent among Hispanics and 2.5 percent among whites. The striking racial disparity in infection rates does not appear to be explained by differences in frequency of risky sexual behavior, according to researchers at the CDC today. African-American gay men were actually somewhat less likely than other groups to report having unprotected sex or having multiple partners. Gayle said the high rate of new infections among African-American gays may be occurring because such men are seeking sexual partners among relatively small groups of people where the frequency of HIV infections and STDs is already high.

The new findings on infection rates in gay men are particularly troubling because efforts by gays to reduce HIV transmission were major reasons for a dramatic, nationwide decline in infection rates in the 1980s. (Washington Post, 08/13/01, Susan Okie)

Study: HIV Infection from Receptive Oral Sex Is Rare

A study by researchers from University of California, San Francisco's (UCSF) Center for AIDS Prevention Studies (CAPS) found the probability of HIV infection through unprotected receptive oral sex with a man to be statistically estimated as zero. "Our study looked at exclusive receptive oral intercourse with a male partner, and we found that the probability of acquiring HIV through that specific sexual activity is very, very low. Given that the results are based on a relatively small sample, we can not rule out the possibility that the probability of infection is indeed greater than zero," said study lead author Kimberly Page Shafer, Ph.D., M.P.H., assistant professor of medicine at UCSF.

The study, presented at the Second National HIV Prevention Conference in Atlanta, enrolled 198 participants from anonymous testing and counseling sites in San Francisco. Ninety-eight percent of the participants were male and 100 percent identified as gay or bisexual. The participants reported no anal or vaginal sex or injection drug use in six months prior to entering the study. The participants reported a median of two receptive oral intercourse partners, and 98 percent reported unprotected receptive oral intercourse. Twenty percent of the participants reported receptive oral intercourse with an HIV-positive partner. Of that group, 89 percent did not use a condom and 40 percent swallowed ejaculate.

The participants were screened for HIV infection and also for recent HIV infection using both the standard test for HIV and a test for HIV that is "detuned" to detect only those HIV infections that have occurred within the six months prior to taking the test. Out of the 198 participants, only one HIV infection was reported, and that infection had not been recently acquired and could not be attributed to the period of exclusive oral receptive intercourse. No recently acquired HIV infections were reported by any of the other participants in the study. Statistically, the study yielded a zero probability of acquiring HIV orally. The study is funded by the National Institute of Dental and Craniofacial Research. (Associated Press, 08/14/01)

Dilemma in Fight Against AIDS

Health professionals hoping to slow the American AIDS epidemic find themselves at a crossroads, at which the treatments that allow individuals with HIV to live longer raise enormous challenges for preventing further spread of the virus. "We are at a transition point in HIV prevention in so many ways," CDC AIDS chief Dr. Helene Gayle said in her closing remarks. "We don't have to go far to see the impact HIV is having on our lives. It's all around us."

Dr. Tom Quinn of Johns Hopkins Medical School reported last year that HIV-positive Ugandans whose viral load exceeded 50,000 viruses per milliliter of blood were 12 times more likely to infect their HIV-negative spouses than those whose viral loads were less than 1,500. His findings prompted 138 Harvard faculty members to call for widespread treatment of HIV-infected Africans. But at the conference, Dr. Kenneth Mayer of Brown University warned that Quinn's findings might not be relevant because the Ugandans were not receiving treatment: The individuals' own immune systems were somehow managing to control the virus, and that might have relevance to how infectious they were. Even so, Quinn suggested that the drugs might slow the US epidemic if every American whose viral load exceeds 10,000 viruses per milliliter were on treatment -- a difficult goal, given that about 30 percent of infected Americans do not even know they have the virus.

Late diagnosis was a major topic of discussion. The CDC's Dr. Michael Campsmith reported on a study in which 40 percent of persons were diagnosed with HIV within a year of receiving an AIDS diagnosis. A Kaiser Permanente research project found that 44 percent of individuals studied were not diagnosed with HIV until they had advanced to AIDS. A Chicago Department of Public Health study revealed that among men treated in city clinics for syphilis, one-third of heterosexuals and one-fourth of gay men had never had an HIV test.

Cornelius Baker, head of Washington, D.C.'s Whitman-Walker Clinic, along with representatives from the National Association of People with AIDS and four other treatment groups, endorsed the CDC's plan to slow the American epidemic to 20,000 new infections a year by 2005 at an estimated annual cost of $300 million annually. (Newsday (NY), 08/16/01, Laurie Garrett)

Critics at AIDS Chief's Debut

In the first public speech of his four-month tenure, White House Office of National AIDS Policy Director Scott Evertz faced an openly skeptical audience. "I need your feedback," Evertz said in response to repeated interruptions and catcalls during his address to the Second National HIV Prevention Conference.

"There really is no room for inequality or disparity in our work," Evertz said. "If we can't talk about men who have sex with men, sex workers and their clients, transgenders, and injecting drug users, we can't do our jobs." "Does your boss know that?" an audience member shouted in reference to President Bush. "Yes, my boss does know that," Evertz responded. "My presence [here] really is the best way to convey to you that the Bush administration really does care about AIDS. . . . It's hard in times of urgency to ask for patience, but I ask you to be patient."

Until this week, Evertz had been invisible to the AIDS community. In an interview, he said Washington rumors asserting that the White House was keeping him muzzled were false: "I have never been told what I can and cannot say." Evertz said that his address on Tuesday was the first of many he expects to make as he visits community-based AIDS organizations around the country.

Earlier this year, members of the Bush administration drew criticism from both Congress and the AIDS community when they told reporters that the AIDS office would be eliminated. Bush subsequently said he had no intention of closing the office and in April appointed Evertz to head it. Conservatives decried Evertz' appointment because he is openly gay; liberals were troubled by his credentials as an anti-abortion Christian activist; and AIDS professionals expressed doubts because Evertz had no science or health background and had never worked on AIDS issues.

This week Evertz acknowledged that his absence from public appearances has contributed to an erosion of his office's credibility. He said he has been on a steep learning curve, studying the scientific and social literature on AIDS. "And I care deeply about those people who are living with AIDS. You know I have to do a lot to address the credibility issue. I recognize that," he said. (Newsday (NY), 08/15/01, Laurie Garrett).

A "Chilling Portrait" of Failure to Prevent AIDS

A day after health officials acknowledged that sharp declines in AIDS cases and death have ended, studies presented at the Second National HIV Prevention Conference in Atlanta highlighted failures to adapt to a changing epidemic. "It is a chilling portrait. It's not a good picture," said Phill Wilson, executive director of the African American AIDS Policy and Training Institute in Los Angeles. "At least it provides a blueprint of what we need to do."

Of huge concern is that 41 percent of people learn of their HIV-positive status a year or less before they find that they have full-blown AIDS. The news is disturbing to researchers because HIV takes a median of ten years to reach full-blown AIDS.

Untested people are unwittingly passing the virus along to their sexual partners and missing out on early drug interventions that could extend their lives.

Dr. Ronald Valdiserri, the CDC's deputy director of HIV, STD and TB Prevention, said he is dismayed that "In 2001, we still have a situation . . . where four out of 10 people are not testing until very late in the course of infection, often when they present with symptoms of AIDS."

For years, the CDC and public health agencies have focused their attention on uninfected people. But the new data argue for curbing risky behaviors among the 800,000 to 900,000 people who already have HIV and AIDS. Many of those are dangerously outside the reach of the health system, according to Dr. Tom Coates, director of the Center for AIDS Prevention Studies at the University of California-San Francisco. "These [people] are the marginalized of the marginalized," Coates said. "These are people who use substances, have problems with alcohol, have difficult childhoods. They have trouble forming intimate relationships . . . and they are more likely to have one-night stands."

Part of prevention for hard-to-reach populations is ensuring that they have a stable living environment. Los Angeles County and San Francisco have received grants from the CDC to develop new outreach services, particularly for racial and ethnic minorities. (Los Angeles Times, 08/15/01, Charles Ornstein).

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